Concussion Clinic Note (Return-to-Learn/Return-to-Play)

Date/Time: [Date and time of encounter]

Provider: [Provider name and credentials]

Visit Type: [Initial / Follow-up / Clearance / Prolonged Symptoms]

Injury Date: [Injury date] Days Since Injury: [Number of days]

Sport/Setting: [Sport, level, practice vs competition, position if relevant]

Source of History: [patient / parent-guardian / coach-ATC / outside records]

ATC Contact: [Name, role, contact information] (Only include if available)

Chief Concern

[Single-line reason for visit including sport, injury date if initial, and primary symptoms or needs such as RTL/RTS guidance]

History of Present Illness

Injury Event: [Mechanism (fall/collision/impact), direction of force, protective equipment worn, immediate signs observed] [Removed from play same day: yes/no/unknown] [Continued play after injury: yes/no/unknown] [Initial evaluation location and by whom] [Imaging performed and results if known] (For initial visits, document in detail. For follow-ups, summarize in 1-2 sentences and focus on interval changes.)

• Loss of consciousness: [yes / no / unknown] (If yes, include estimated duration)
• Amnesia: [retrograde: yes/no/unknown with duration] [anterograde: yes/no/unknown with duration]
• Seizure-like activity: [yes / no / unknown]
• Neck pain: [yes / no / unknown]

Interval Summary: [Changes in symptoms, function, and activities since last visit] (For follow-up visits only)

Symptom Course: [Onset: immediate/delayed] [Trajectory: improving/worsening/fluctuating] [Provoking factors: schoolwork, screens, reading, noise, light, exertion, car rides] [Relieving factors] [Sleep changes] [Mood/behavior changes]

Current Treatments and Activity: [Rest patterns] [School attendance and PE restrictions] [Medications tried with response] [Therapies: vestibular PT, vision therapy, counseling]

Risk Factors: (Document presence, absence, or unknown for each)

• [Prior concussions: number and recovery course]
• [Personal migraine history: yes/no/unknown]
• [Family migraine history: yes/no/unknown]
• [ADHD or learning disorder: yes/no/unknown]
• [IEP/504 status: yes/no/unknown]
• [Anxiety or depression history: yes/no/unknown]
• [Sleep disorder history: yes/no/unknown]
• [Vestibular sensitivity or motion sickness history: yes/no/unknown]
• [Medications affecting symptoms or testing]

Symptom Inventory

Instrument: [PCSS / PCSI / SCAT symptom scale / other] (If none administered, state no standardized scale was administered and provide brief free-text symptom summary)

• Scores: [Total symptom count] [Total severity score]
• Top symptoms: [3 highest-severity symptoms]
• Global rating: [Percent of normal and/or improvement since last visit]
• Symptom provocation: [Behavior with exertion] [Behavior with schoolwork]

Red-Flag Screening

(Document presence or absence since injury—or since last visit for follow-ups. If any are present, document disposition.)

• [Worsening headache: present / absent]
• [Repeated vomiting: present / absent]
• [Seizure or convulsions: present / absent]
• [Increasing confusion or agitation: present / absent]
• [Focal weakness or numbness: present / absent]
• [Slurred speech: present / absent]
• [Excessive drowsiness or difficulty waking: present / absent]
• [Unequal pupils: present / absent]
• [Double vision: present / absent]
• [Inability to recognize people or places: present / absent]
• [Young children: inconsolable crying, refusal to eat: present / absent] (Include for young children only)

Disposition if red flag present: [ED referral / imaging / observation plan and instructions] (Only include if red flag present)

School and Functional Status

[Grade/year] [Current attendance: full/partial/out] [Existing supports: IEP/504/MTSS/none/unknown] [Baseline academic performance] [Current symptom barriers: reading tolerance, test-taking, noise/light sensitivity, screen requirements, hallway transitions] [PE and recess participation status]

[Driving status and symptoms with driving] (Include for teens and adults)

[Work role, physical/cognitive demands, current work status, symptom barriers] (Include for non-students)

Relevant History

[Focused PMH relevant to concussion] [Current medications] [Allergies] [Family history: migraine, neurologic disease] [Substance use if safety-relevant] (Keep concise—avoid unrelated details)

Examination

• Vitals: [BP, HR, RR, SpO2, Temp, pain score] [Orthostatic vitals if performed]
• General/Head/Face: [Signs of trauma, scalp findings]
• Cervical Spine: [Range of motion, tenderness, provocative findings, neurologic signs]
• Neurologic: [Mental status/orientation] [Focused cranial nerves] [Motor strength and sensation] [Coordination] [Gait]
• Vestibulo-ocular/Oculomotor: [Smooth pursuits] [Saccades] [Convergence/NPC] [VOR] [Visual motion sensitivity] [Symptom provocation] (Document each as performed-normal, performed-abnormal with details, or not performed with reason)
• Balance/Postural Stability: [Tandem gait] [Single-leg stance] [mBESS or other with scores] [Symptom provocation] (Document only if assessed)

(For specialized concussion exam elements, do not default to normal—explicitly document as performed-normal, performed-abnormal with details, or not performed with rationale.)

Standardized Assessment

(Include only if formal assessment tools were used; omit section entirely if none)

[Tool name and version] [Components completed] [Scores/findings] [Validity considerations: language barrier, effort, pain, fatigue] [Baseline availability for comparison]

Diagnostics Reviewed

[Imaging (CT/MRI) results] [ED/Urgent Care notes] [ATC logs or school reports] [Other external records] (If none, state none or omit section)

Assessment

(List problems in descending clinical priority. For each, include working diagnosis, supporting evidence, time course, and risk modifiers. Document differential reasoning when symptoms have competing explanations. Do not state recovered without documenting symptom status at rest and with exertion, exam normalization, and functional tolerance.)

[Problem 1]: [Diagnosis]

[Supporting evidence and timeframe] [Risk modifiers present] [Differential considerations if applicable]

[Problem 2]: [Diagnosis]

[Supporting evidence and timeframe]

(Add additional problems as needed)

Plan

Education and Counseling

• [Diagnosis explanation and expected course]
• [Relative rest guidance: brief 24-48 hours, then gradual return to non-contact activities as tolerated]
• [Individualized screen guidance based on symptoms]
• [Sleep hygiene, hydration, nutrition reinforcement]
• [No contact or collision risk until cleared]
• [Red-flag precautions reviewed and understanding confirmed]

Return-to-Learn Plan

Current RTL stage: [out of school / partial day / full day with supports / full day without supports]

Accommodations recommended: [Reduced homework/classwork volume] [Extra time for assignments/tests] [Rest breaks in quiet location] [Printed notes or reduced copying] [Reduced screen brightness/limited prolonged screen blocks] [Preferential seating away from bright light/noise] [Staggered hallway transitions] [Quieter lunch setting] [PE and recess restrictions aligned with RTS stage] (Select applicable accommodations)

Start date: [Date] Review date: [Date]

(If school supports are unknown, document unknown and provide interim symptom-based guidance)

School Accommodations Letter

Student: [Name] DOB: [DOB] School: [School] Grade: [Grade]

Diagnosis: Sport-related concussion sustained [Injury date]. The following temporary accommodations are recommended through [Review date] or until updated:

• [Attendance modifications]
• [Academic workload reduction and extended time]
• [Scheduled rest breaks in quiet area as needed]
• [Screen modifications]
• [Environmental modifications]
• [Testing accommodations]
• [PE restrictions aligned with RTS stage]

Provider: [Name, credentials, contact] Date: [Date]

Return-to-Activity / Return-to-Sport Plan

Current step authorized: [Step 1: return to regular activities including school / Step 2: light aerobic activity / Step 3: moderate activity / Step 4: heavy non-contact activity and sport-specific drills / Step 5: full-contact practice after medical authorization / Step 6: return to competition]

• Progression criteria: Minimum 24 hours per step; advance only if no new or worsening symptoms; if symptoms recur, stop and return to prior step after symptom resolution
• Supervision: [ATC / coach / parent / self with guidance]
• Final clearance authority: [Clinician name/role for contact and competition clearance]
• Same-day RTP: No same-day return to play when concussion is diagnosed or suspected

[Graded physical activity guidance with pacing and symptom monitoring] (For non-athletes)

Targeted Symptom Management

• Headache: [Analgesic approach, medication overuse prevention, preventive strategies]
• Sleep: [Sleep hygiene strategies; short-term aids if needed; avoid daytime hypersomnia]
• Vestibular/Ocular: [Home strategies; vestibular/vision rehab referral if persistent or abnormal testing]
• Neck pain: [Cervical PT consideration; posture/ergonomic guidance]
• Mood/Anxiety: [Reassurance, coping strategies, behavioral health referral if indicated]
• Cognitive intolerance: [Pacing, scheduled breaks, task chunking, reduced multitasking]

(Include only symptom domains that apply to this patient)

Referrals

[Referrals placed with indication: concussion specialist, neuropsychology, vestibular therapy, vision therapy, behavioral health, sleep medicine] (Include only if referrals made)

Escalation criteria reviewed: Worsening symptoms, red flags, persistent symptoms beyond 2-4 weeks, inability to tolerate school/work despite accommodations

Follow-Up

Interval: [Follow-up timing, typically 7-14 days]

Reassess: [Symptom score trend, school tolerance, exertional tolerance, exam findings]

Communication: [Plan for ATC/school contact] [Release of information obtained: yes / no]

Clearance Statement

(Include only when making clearance decisions)

Cleared for: [Specific step or activity]

Not cleared for: [Contact practice / competition / PE / driving / other]

Justification: [Symptom status at rest and with exertion, exam findings, functional tolerance, protocol adherence]